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5 PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure Denise Morse, MBA Senior Manager, Quality Analytics, City of Hope National Medical Center Moderator Lisa Vinson, BS, BSN, RN Program Lead, PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Contractor (SC) November 29, 2018

6 Acronyms and Abbreviations ADCC C4QI CAUTI CDI CE CLABSI CMS CST FY HCAHPS Alliance of Dedicated Cancer Centers Comprehensive Cancer Centers Consortium for Quality Improvement catheter-associated urinary tract infection Clostridium difficile Infection Continuing Education central line-associated bloodstream infection Centers for Medicare & Medicaid Services Cancer-Specific Treatment Fiscal Year Hospital Consumer Assessment of Healthcare Providers and Systems ICD-CM IPPS LTCH MRSA NQF PCH PCHQR PPS Q RSRR SC SSI VIQR International Classification of Diseases Clinical Modification inpatient prospective payment system long-term care hospital Methicillin-resistant Staphylococcus aureus bacteremia National Quality Forum PPS-Exempt Cancer Hospital PPS-Exempt Cancer Hospital Quality Reporting prospective payment system quarter Risk-Standardized Readmission Rate support contractor Surgical Site Infection Value, Incentives, and Quality Reporting Back 6

7 Purpose This presentation will discuss the 30-Day Unplanned Readmissions for Cancer Patients (National Quality Forum [NQF] #3188) measure in the PCHQR Program. This discussion will: Explain the development, endorsement, and application of the measure. Assist in understanding the measure specifications. Share lessons learned for the purpose of quality improvement. 7

8 Objectives Upon completion of this program, participants will be able to: Discuss the history of Unplanned Readmissions for Cancer Patients metric development and implementation. Clearly state the requirements and methodology for Unplanned Readmissions for Cancer Patients. Discuss how centers can use the Unplanned Readmissions for Cancer Patients for performance improvement. 8

9 PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure NQF #3188 Overview 9

10 Why is looking at cancer-specific readmissions important? Cancer is the second most common cause of death in the US. There is an estimated 1.7 million new cancer cases to be diagnosed in The incidence is increasing per year as the population is aging. The Agency for Healthcare Research and Quality estimates the direct medical costs for cancer in 2015 were $80.2 billion, with 38% of the cost occurring during inpatient hospital stays.* Unplanned readmissions can contribute to higher costs and lower quality of care. A focused look at potentially preventable readmissions can reveal opportunities for improved patient-centered and quality care at a lower overall cost. *American Cancer Society, Cancer Facts & Figures

11 Current NQF Endorsed Readmissions Metrics Current readmissions metrics do not focus specifically on cancer patients. The current NQF-endorsed readmissions metrics include: All-Cause Readmissions Index Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Acute Myocardial Infarction Hospitalization (NQF #0505) Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Vascular Procedures (NQF #2513) Hospital 30-Day, Risk-Standardized Readmission Rates Following Percutaneous Coronary Intervention (NQF #0695) Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease Hospitalization (NQF #1891) Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure Hospitalization (NQF #0330) 11

12 C4QI and ADCC Collaboration The Comprehensive Cancer Center Consortium for Quality Improvement (C4QI) is a collaborative group of centers that meets regularly to share best practices with the goal of improving quality for all cancer patients. The C4QI centers recognized the need for a readmissions measure that would help focus on potentially preventable readmissions and provide opportunities for improvement. Using a shared database, the C4QI centers went through several iterations of the metric inclusions and exclusions. The cancer centers worked with their physicians, clinical staff, ancillary staff, and coding/billing teams to identify code sets and applicability to the populations. The Alliance of Dedicated Cancer Centers (ADCC) recognized the applicability of this measure to the PCHQR Program and worked with the NQF to refine and submit the measure specifications for endorsement and use in future program years. 12

13 NQF and PCHQR Program The 30-Day Unplanned Readmissions for Cancer Patients measure was submitted to NQF and received endorsement in The metric was added to the Fiscal Year (FY) 2019 Inpatient Prospective Payment System (IPPS)/Long- Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule. The metric will be reported for the FY 2021 program year and subsequent years. The metric, as written, can apply to all cancer patients at any short-term acute care hospital. 13

14 Readmissions Data Submission and Process 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) is a claims-based measure. No data submission will be required from PCHs. 14

15 Numerator Statement The numerator includes all eligible unplanned readmissions to any short-term acute care within 30 days of the discharge date from an index admission that is included in the measure denominator. Readmissions with an admission type (UB-04 Uniform Bill Locator 14) of emergency = 1 or urgent = 2 are considered unplanned readmissions within this measure. Readmissions for patients with progression of disease (using a principal diagnosis of metastatic disease as a proxy) and for patients with planned admissions for treatment (defined as a principal diagnosis of chemotherapy or radiation therapy) are excluded from the measure numerator. 15

16 Numerator Exclusion Codes The following readmissions are excluded from the measure numerator: 1. Primary Claim Diagnosis Code of metastatic disease (ICD-9-CM range: , ; ICD-10-CM range: C77.0 C79.9, C7B.0 C7B.8) o Rationale: A primary (or principal) diagnosis of metastatic disease serves as a proxy for disease progression. Readmissions for conditions or symptoms associated with disease progression are not reflective of poor clinical care but, rather, advanced disease. 2. Patients with a Primary Claim Diagnosis Code of chemotherapy or radiation encounter (ICD-9-CM range: V58.00 V58.12; ICD-10-CM range: Z51.00 Z51.12) o Rationale: Readmissions are expected and planned for some patients who require additional cancer treatment in the inpatient setting. These readmissions reflects high-quality care that is focused on patient safety and are reliably distinguishable in claims data. 16

17 Denominator Statement The denominator includes inpatient admissions for all adult Fee-for-Service Medicare beneficiaries where the patient is discharged from a short-term acute care hospital (PCH, short-term acute care PPS hospital, or critical access hospital) with a principal or secondary diagnosis (i.e., not admitting diagnosis) of malignant cancer within the defined measurement period. Denominator Exclusions: The following index admissions are excluded from the measure denominator: 1. Less than 18 years of age 2. Patients who died during the index admission 3. Patients discharged against medical advice 4. Patients transferred to another acute care hospital during the index admission 5. Patients discharged with a planned readmission 6. Patients having missing or incomplete data 7. Patients not admitted to an inpatient bed 17

18 Risk Adjustment The rates will be risk adjusted using a logistic regression model. Risk factors for consideration: o o o o o o o Gender Intensive care unit stays Comorbidities Disease type - solid tumor Length of stay Age Discharge location Per the FY 2019 IPPS/LTCH PPS Final Rule, the following equation was used to generate the risk-adjusted 30-Day Unplanned Readmissions for Cancer Patients rate: 18

19 PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure Use of NQF #3188 in Performance Improvement at City of Hope 19

20 Performance Improvement Utilization City of Hope is currently using the 30-Day Unplanned Readmissions for Cancer Patients measure as part of the internal quality reporting and performance improvement. The measure is part of a readmissions task force, embedded into the physician department quarterly quality reports, and included on The Joint Commission-mandated ongoing professional practice evaluations. There are three specific performance improvement projects: o Cystectomy o Post-discharge phone calls o Symptom management/triage support 20

21 Performance Improvement Project: Cystectomy The initial project following the creation of the measure focused on surgical readmissions. Data from the Vizient/University HealthSystem Consortium database showed City of Hope had a higherthan-expected rate of readmissions post-cystectomy. o City of Hope had a 30% higher rate of readmissions than the aggregate of the other cancer centers. Using the readmission measure, we isolated the patient population with potentially preventable readmissions. o The metric specifications allowed the team to remove the planned admissions and focus on patients admitted for more acute conditions. 21

22 Performance Improvement Project: Cystectomy (continued) The reasons for readmissions were the following: o Fever o Dehydration o Complications The symptom-related reasons for admission were concerning and led to opportunities for improvement in outpatient management of patients, including discharge instructions and more timely follow-up visits. This discovery led to the creation of the Cystectomy Care Pathway which focused preventing future readmissions AND completely changing the way these patients were treated from initial consultation through the post-operative period. 22

23 Performance Improvement Project: Post-Discharge Phone Calls Use of the metric also identified opportunities to reduce post- stem cell transplant readmissions in both the autologous and allogeneic populations. A review of the data for the transplant patient population showed that those patients who were readmitted could benefit from additional post-discharge support to answer questions and identify potential health outcomes earlier. A pilot program was started to provide post-discharge follow-up phone calls to all inpatient transplant discharges. The results showed an almost 30% decrease of readmissions in the population and sustained reduction during the past two years. 23

24 Performance Improvement Project: Symptom Management/Triage Support Currently, City of Hope uses data from the readmissions metric to work on improving overall symptom management and triage support tools. The data from the readmissions metric helps inform the work with patients most at risk for readmission, symptoms most often seen in readmitted patients, and services that could serve as pilot populations. 24

25 Resources FY 2019 IPPS/LTCH PPS Final Rule (83 FR through 41616) NQF measure specifications: All-Cause Admissions and Readmission Portfolio 25

26 PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure Key Dates and Reminders 26

27 Important Upcoming Dates Tentative Outreach and Education Event Dates o December 19, 2018 o January 24, 2019 Upcoming Data Submissions o January 3, 2019 Quarter (Q) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey o February 15, 2019 Q Cancer-Specific Treatment (CST) hormone data Q healthcare-acquired infection measure data CLABSI, CAUTI, CDI, MRSA, and SSI 27

28 Hospital Compare Key Dates February 2019 Refresh o Contains: Q through Q CST chemotherapy data Q through Q CST hormone data Q through Q HCAHPS Survey data Q through Q Oncology Care Measure data Q through Q External Beam Radiotherapy data o Preview period: December 1 31, 2018 o Anticipated refresh date: February 13, 2019 April 2019 Refresh o Contains: Q through Q CST chemotherapy data Q through Q CST hormone data Q through Q HCAHPS Survey data o Tentative preview period: February 1 March 2, 2019 o Tentative refresh date: April 25,

29 Accessing the QualityNet Questions and Answers Tool QualityNet Questions and Answers Tool 29

30 PCHQR Program: Overview of the 30-Day Unplanned Readmissions for Cancer Patients (NQF #3188) Measure Questions 30

31 Disclaimer This presentation was current at the time of publication and/or upload onto the Quality Reporting Center and QualityNet websites. Medicare policy changes frequently. Any links to Medicare online source documents are for reference use only. In the case that Medicare policy, requirements, or guidance related to this presentation change following the date of posting, this presentation will not necessarily reflect those changes; given that it will remain as an archived copy, it will not be updated. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. Any references or links to statutes, regulations, and/or other policy materials included in the presentation are provided as summary information. No material contained therein is intended to take the place of either written laws or regulations. In the event of any conflict between the information provided by the presentation and any information included in any Medicare rules and/or regulations, the rules and regulations shall govern. The specific statutes, regulations, and other interpretive materials should be reviewed independently for a full and accurate statement of their contents. 31